/ 2 April 2014

Can we end Aids in Africa?


It is true to say that the extraordinary shift in the global response to the HIV epidemic in sub-Saharan Africa over the past 15 years has been one of humanity's shining achievements in recent times. The enormity of the scale of the implementation of treatment, care and prevention across the continent has undoubtedly contributed to better health globally.

The roll-out of antiretroviral therapy (ART), surely one of the greatest scientific developments in recent history, has saved an estimated nine million life-years in sub-Saharan Africa.

According to the 2012 Joint United Nations Programme on HIV and Aids (Unaids) global report on the Aids epidemic, 56% of eligible people on the African continent were receiving ART in 2011. This is higher than the global average of 54%, and, yes, is still nowhere near where we'd want it to be.

But if we recall what pending disaster we were facing at the beginning of the 2000s, one simply has to acknowledge that the transformation of the epidemic and the health infrastructure and systems in many countries resemble a revolution of sorts. Botswana, Namibia, Rwanda, Swaziland and Zambia have all achieved universal access to ART, in other words, more than 80% of those eligible for it have access to ART.

The Human Sciences Research Council's (HSRC) National HIV Prevalence, Incidence and Behaviour Survey that was released this week has confirmed that ART access in South Africa doubled in the country between 2008 and 2012, with South Africa now having the largest public sector ART programme in the world.

ART has dramatically driven down both new HIV infections and Aids-related deaths. According to Unaids, new HIV infections declined by 50% in the past decade and Aids deaths by 25% between 2005 to 2011. This trend started in the mid-2000s, in large part because of the availability of antiretroviral drugs.

The HSRC report has, however, revealed a worrying trend in South Africa. While the country's new HIV infection rate, or HIV incidence rate, declined among female youths, it remains at unacceptably high levels. In the older population the incidence did not show signs of slowing down. The number of new HIV infections is the highest in the world.

The number of HIV infected pregnant women in Africa who receive preventative ART that significantly reduces their chances of infecting their babies during pregnancy, labour or breastfeeding, has dramatically increased. In countries such as South Africa and Botswana, access is close to 100%. The HSRC report has shown the infection among children under 12 months has declined since 2008, confirming the success of mother-to-child transmission programmes in South Africa.

This is all good news, but looking ahead we need to couch our speech about what remains to be done. I say this too, very cognisant of the fact that we are less than a year away from a pivotal time in the HIV and Aids response, when consideration of the 2015 Millennium Development Goals, and those "targets" that will succeed them, will take up much of the space of the global health agenda.

We are, make no mistake, at a critical juncture in sub-Saharan Africa's Aids epidemic. It is clear that substantial barriers remain to ending the epidemic and it is in everyone's interests that they are addressed in the conversations about a post-2015 scenario.

In a nutshell: sub-Saharan Africa, despite all the impressive gains listed above, still shoulders a vastly disproportionate burden of the epidemic. According to the 2012 Unaids report, the continent accounted for 71% of all new infections globally in 2011, more than 90% of children infected with HIV and 70% of Aids-related deaths.

One needs to be mindful when generalising statistics. The "good news" about declining new HIV infections and Aids deaths is not shared evenly across regions or countries. HIV incidence is, for instance, still on the rise in Guinea-Bissau and is only stable in countries like Tanzania, Uganda, Nigeria, Gambia , Lesotho, Gambia, Democratic Republic of Congo, Benin and Angola, according to the Unaids.

ART coverage reveals a similarly uneven pattern. Universal ART coverage in Botswana, Namibia, Rwanda, Swaziland and Zambia is an extraordinary step forward. But the Unaids report notes that 12-million people on the continent, a third of the global number of people living with HIV, are still unable to access ART. This is an extraordinary impediment to ending Aids in Africa.  

Underdeveloped health systems, mismanagement and corruption, political turmoil and the lack of accessibility to remote areas all play their part to prevent wider ART coverage. It is vital that African governments and organisations such as the Global Fund to Fight Aids, TB and Malaria keep working towards the international commitment of universal coverage by 2015. The key to success will be maintaining this high level of ART coverage, which requires a gradual switch from international funding to sustainable domestic funding.

Even in situations where people have been accessing treatment, retention rates have sometimes become barriers in themselves. According to the Unaids report, nearly half of all people in Malawi and 40% in Kenya who started ART in the mid-2000s were no longer on treatment five years thereafter.

But getting people on treatment and on to care is only half the solution: prevention plays a key part in HIV management.

There is now also an urgent need for a discussion among academics, health professionals, activists and bureaucrats around the post-2015 scenarios if the response to HIV is to continue in the right direction. While so much has changed, too much has stayed the same.

Gender inequality continues to see women share the burden of the epidemic – 58% of people with HIV in sub-Saharan Africa are female, according to Unaids. The HSRC report has revealed that the HIV incidence rate among South African females aged 15 to 24 is four times higher than the incidence rate found in males in this group. Among the teenage population, the difference between the HIV prevalence between girls and boys is even higher – girls have eight times the infection rate of their male counterparts. The risk factors for females – physiological vulnerability, social and economic inequities, unequal access to education and employment, gender violence, difficulty negotiating sex and condom use, and age-disparate relationships where one sexual partner is more than five years older than the other all fuel the epidemic.

Stigma and discrimination, as they do in so many countries with HIV epidemics, continue to hinder the implementation of science on the ground. And unfortunately much of the problem, if we are frank with ourselves, has been driven by the behaviour of some governments, or at least condoned by decision-makers.

In recent years, much has been made of the punitive anti-homosexuality laws that exist in 35 African countries, and the more recent severe amendments made to them in countries such as Uganda and Nigeria. According to prominent epidemiologists, we have major HIV epidemics among men who have sex with men and in transgender communities. Yet in many sub-Saharan African countries, we are powerless to intervene in any meaningful way because of the fear of reprisal by these governments.

The same could be said to apply to the injecting drug user community. Research studies have confirmed that we have alarming HIV infection rates among injecting drug users, yet it is telling that, even in some international forums, the issue around drug use and HIV doesn't feature prominently on agendas.

The past three decades of HIV and Aids have taught us that the virus doesn't discriminate, but that people and governments do. A renewed engagement with African decision-makers on human rights issues has to take place if we are to move towards ending Aids in sub-Saharan Africa and build on the huge gains we've made over the past 15 years.

Dr Olive Shisana is chief executive officer of the South African Human Sciences Research Council and local co-chair of the 21st International Aids Conference (Aids 2016) taking place in Durban, South Africa between July 17 and 20 2016.